BACKGROUND SCREENING
Application for Exemption
AUTHORITY: In accordance with section 435.07, Florida Statutes, persons disqualified from employment may be granted an
exemption from disqualification. The granting of an exemption does not change an individual’s criminal history. It only provides
eligibility for employment in a health care setting.
An individual seeking an exemption must demonstrate by clear and convincing evidence that an exemption from disqualification should
be granted. The application will be reviewed and a decision made once all relevant documentation listed below has been received.
A person is not eligible to apply for an Exemption from Disqualification until:
o
o
o
o
He/she has been lawfully released from confinement, supervision, or other nonmonetary condition imposed by the court
for a disqualifying misdemeanor criminal offense;
At least 3 years after he/she has been lawfully released from confinement, supervision, or other nonmonetary condition
imposed by the court for a disqualifying felony criminal offense.
He/she has completed any court-ordered fee, fine, fund, lien, civil judgment, application, costs of prosecution, trust, or
restitution as part of the judgment and sentence for any disqualifying felony or misdemeanor in full.
Persons designated as sexual predators, sexual offenders or career offenders are not eligible for an Exemption from
Disqualification.
APPLICATION CHECKLIST:
The following items must be included with this Application for Exemption from Disqualification:
A current Level II screening was conducted electronically through the Agency for Health Care Administration or the Care
Provider Background Screening Clearinghouse by an approved live scan vendor. (For more information regarding Level II
background screenings, please visit: http://ahca.myflorida.com/backgroundscreening.)
Arrest reports for all offenses listed on the criminal history report. The arrest report is a detailed narrative that explains the
reason for your arrest. Arrest reports may be obtained from the law enforcement (police department, sheriff’s office, etc.)
agency that made the arrest.
Court dispositions for all offenses listed on the criminal history report. Court dispositions may be obtained from the
clerk of the court in the county in which you were arrested. The disposition is the court document that states what you
were actually sentenced for and the conditions of your sentence.
Signed Statement (only needed if you cannot obtain the arrest report and/or court disposition): Please write a detailed
statement on each arrest explaining why you were arrested. You must include the victim’s age and relationship to you and the
sentence you received (probation, jail, prison, etc.). If your offense was related to theft, please include the item(s) and the
approximate value of the item(s) stolen. Documentation from the clerk of court and/or the arresting agency must be provided
on letterhead indicating the document(s) are no longer available. Please make sure you sign the statement.*
If you were given probation or parole, you will need a letter from the probation department with the following information
required for each offense: the date you started probation or parole; the date you are scheduled to terminate probation or
parole; if you are eligible for early termination of probation or parole; if you have violated probation or parole; and if so, what
was the violation.
Provide 3-5 letters of reference. One reference letter must be from a current or most recent employer on the employer’s
letterhead. Other letters must be from individuals you have known for at least two years through contact at the workplace,
community activities, education, or training centers. Individuals providing a letter of recommendation should include their
name, address, and telephone number for verification or possible interview.
Documentation of rehabilitation. Rehabilitation includes successful completion of a court-ordered treatment or counseling
program, educational, or training certificates, proof of participation in community activities, special recognition, or awards
received.
AHCA Form #3110-0019, May
Page 1 of 6
2015
Rule 59A-35.090
Form available at: http://ahca.myflorida.com/BackgroundScreening
Where to send the application:
•
The Agency reviews applications and makes decisions for Exemptions for:
-
unlicensed personnel working for a health care provider
facility owner, administrator, or chief financial officer
Medicaid Provider Enrollment
Medicaid Managed Care Health Plan
Send your application to:
Background Screening Unit
Agency for Healthcare Administration
2727 Mahan Drive MS #40
Tallahassee, FL
32308 (850) 412-4503
The Department of Health reviews applications and makes decisions for licensed and certified health care
professionals as long as that person is working in the scope of his or her license or certification.
For more information regarding the exemption process for licensed or certified individuals with the
Department of Health, visit http://www.floridahealth.gov/ or by calling 850-245-4444.
AHCA Form #3110-0019, May
Page 2 of 6
2015
Rule 59A-35.090
Form available at: http://ahca.myflorida.com/BackgroundScreening
AHCA Use Only
Date Received:
Date 1 Reviewed:
Date Omissions Sent:
Date Appl. Complete:
Hearing? Y N
Decision Date:
st
BACKGROUND SCREENING
Application for Exemption
AUTHORITY: In accordance with section 435.07, Florida Statutes, this application is submitted for an Exemption from Disqualification
to seek employment in a health care setting for which employment was denied due to a disqualifying criminal history offense.
Disclosure of your social security number is voluntary. The Agency for Health Care Administration shall use such information for
purposes of internal identification.
NOTE: The granting of an exemption by any State Department (including this Agency) does not clear the criminal history. The
exemption only provides eligibility for employment despite the presence of a disqualifying offense(s). The exemption only
provides eligibility for employment despite the presence of a disqualifying offense(s). If granted, an exemption shall be voided
if you receive a new disqualifying criminal offense after the date the exemption is issued.
1. PERSONAL INFORMATION
Please select any of the following that apply:
I applied for employment with a health care provider in a position that does not require licensure or certification (i.e. Dietary,
homemaker or companion sitter, home health aide, etc.) and must obtain an exemption before I can work.
I am an owner, administrator or chief financial officer for a health care provider that is currently licensed or seeking licensure by the
Agency.
I have submitted an application for enrollment as a Medicaid Provider.
I am employed with a Medicaid Managed Care Health Plan. Principals of the provider entity include any officer, director, billing
agent, managing employee, or affiliated person, or any partner or shareholder who has an ownership interest equal to 5 percent or
more in the provider.
NOTE: If you are seeking an exemption to work as a CNA, RN, LPN or other licensed or certified position, please contact the appropriate
licensing board at the Department of Health.
Last Name:
First Name:
Middle Name:
Mailing Address:
Maiden Name:
Phone Number: Please include Area Code
City:
State:
Zip:
Social Security Number:
Date of Birth: mm/dd/yyyy
Sex:
List All Prior Names, Aliases, AKAs:
Race:
Email: Optional
M
White
Black
Asian or Pacific Islander
F
Indian
Other:
(INDICATE HISPANIC AS BLACK OR WHITE BASED ON SKIN COLOR)
Have you applied for an exemption from disqualification with another state agency?
If yes, complete the following:
YES
NO
State Agency where exemption request was submitted: (i.e. Department of Children and Families, Department of Health, etc.)
Date of decision:
Date application submitted:
Exemption decision:
Granted
Denied
Withdrawn
Still under review
NOTE: Even if you have received an exemption from disqualification from another state agency, you are still required to apply for an
exemption through this Agency. Proof of exemption must be provided with the application. The Agency will take into
consideration any exemption that is granted through another state agency when making a decision.
AHCA Form #3110-0019, May
Page 3 of 6
2015
Rule 59A-35.090
Form available at: http://ahca.myflorida.com/BackgroundScreening
2. EMPLOYMENT INFORMATION
Name of Provider where you are employed or seeking employment:
Street Address:
Phone Number: Please include Area Code
City:
State:
Zip:
Please select the type of health care provider for which you work or were denied employment due to your criminal history:
Adult Day Care Center
Adult Family Care Home
Assisted Living Facility
Community Mental Health
Crisis Stabilization Unit
Durable Medical Equipment
Health Care Clinic
Health Care Services Pool
Home Health Agency
Home Medical Equipment
Homemaker/Companion Service
Hospice
ICF/DD
Nurse Registry
Nursing Home
Prescribed Pediatric Extended Care
Residential Treatment Facility/Center
Other:
Please select the type of position you are seeking an exemption. NOTE: Nurses, Certified Nursing Assistants and other professions
licensed or certified through the Department of Health (DOH) must apply for an exemption through the appropriate licensing board at DOH.
Administrator
Chief Financial Officer/
Dietary
Home Health Aide
Owner / Operator w/ 5% or more interest
Mental Health Personnel
Risk Manager
Homemaker/Companion Sitter
Maintenance
Nursing Assistant (non-certified)/Patient Aid
Relief Person
Employee / Staff Person
Other:
3. EMPLOYMENT HISTORY
Identify the name and address of each employer, supervisor, address, telephone number, dates of employment and your
job responsibilities for the last 5 years. Please explain any breaks in employment that exceed 3 months. Attach
additional sheets if necessary.
Current or Most Recent Employer:
Supervisor’s Name:
Address:
Telephone Number:
(include area code)
Job Title:
Employment Dates:
Job Responsibilities:
Reason for Leaving:
Employer:
Supervisor’s Name:
Address:
Telephone Number:
(include area code)
Job Title:
Employment Dates:
Job Responsibilities:
Reason for Leaving:
AHCA Form #3110-0019, May
Page 4 of 6
2015
Rule 59A-35.090
Form available at: http://ahca.myflorida.com/BackgroundScreening
Employer:
Supervisor’s Name:
Address:
Telephone Number:
(include area code)
Job Title:
Employment Dates:
Job Responsibilities:
Reason for Leaving:
Employer:
Supervisor’s Name:
Address:
Telephone Number:
(include area code)
Job Title:
Employment Dates:
Job Responsibilities:
Reason for Leaving:
Employer:
Supervisor’s Name:
Address:
Telephone Number:
(include area code)
Job Title:
Employment Dates:
Job Responsibilities:
Reason for Leaving:
4. EDUCATION / TRAINING
Please complete the following and include copies of any certificates, diplomas, and licenses if applicable.
1.
What is your highest level education completed?
Did not complete high school
GED or equivalent
High School Diploma
AA Degree
BS/BA degree
Master’s Degree
Doctorate
Other:
2. Are you enrolled in or have you completed a training program to obtain certification or professional licensure in a
health-related occupation?
Yes
No
If Yes, please complete the following:
Type of Training
(Home Health Aide, Nursing
Assistant, etc.)
Name of School/Program
AHCA Form #3110-0019, May
Page 5 of 6
2015
Date of Training
Training Completed?
Certificate or
License Received?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Rule 59A-35.090
Form available at: http://ahca.myflorida.com/BackgroundScreening
3. Are you a licensed or certified health care professional?
Yes
No
If yes, please provide your license or certificate number:
4. Have you registered for examinations required to obtain certification or professional licensure in a health related
occupation?
Yes
No
If yes, please complete the following:
Type of Exam
Date Applied for Exam
Date of Exam
5. CONFIRMATION TO REQUEST AN EXEMPTION REVIEW
By submitting this application I formally request an exemption review in accordance with section 435.07, Florida Statutes.
The information in this application and the documents I have provided are true and correct. I understand that it is my
responsibility to provide clear and convincing evidence that I will not pose a danger to the health or safety of health care
patients or their property. I also understand that the decision of the Agency for Health Care Administration regarding this
exemption may be contested through a hearing requested under the provisions of Chapter 120, Florida Statutes.
I understand that information and documents submitted in this application are public records and shall be subject to public
inspection as provided for in Chapter 119, Florida Statutes, except for information exempted by law from public viewing.
* Pursuant to § 837.06, F.S., whoever knowingly makes a false statement in writing with the intent to mislead a public
servant in the performance of his or her official duty shall be guilty of a misdemeanor of the second degree, punishable as
provided in § 775.082, F.S., or § 775.083, F.S.
Please Print Your Name
Signature
AHCA Form #3110-0019, May
Page 6 of 6
Date
2015
Rule 59A-35.090
Form available at: http://ahca.myflorida.com/BackgroundScreening